Mental and Physical Health Consequences of the Stigma Associated with Mental Illnesses
Abstract and Keywords
People with mental illnesses experience physical illness and premature mortality at much higher rates compared to people without such illnesses. This chapter proposes that the stigma of mental illness comprises an important set of causes of this physical health disparity. It draws on classical and modified labeling theory from sociology for insights and propositions as to why mental illness stigma might affect physical health. The chapter proposes that the stigma of mental illness might affect not only the future experience of mental illness but also a broad range of physical illnesses, thereby contributing to the substantial physical health disparity that people with mental illnesses experience. The chapter develops a conceptual model that places at its center stigma processes including structural, interpersonal, social psychological, and internalized processes. Stigma processes at these levels induce stress and reduce resources, which in turn compromise physical health to produce large physical health disparities.
Generations of research has probed the stigma of mental illnesses, identifying them as ones that are subject to strong and enduring stigma (Link & Stuart, 2016; Pescosolido et al., 2010). In keeping with the theme of this part of the book, we discuss bidirectional processes in the area of mental illness stigma—specifically, how mental illness might induce stigma, which then affects the persistence or reoccurrence of mental illness. Furthermore, given the overall physical illness theme of the volume, we emphasize ways in which mental illness stigma can affect physical health outcomes. Specifically, we construct an explanatory model that identifies how mental illness stigma might be implicated in the production of physical and mental health outcomes.
In this chapter, the term mental illnesses refers to the kinds of disorders described in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013) and the kinds of pathological conditions depicted in the National Institute of Mental Health’s Research Domain Criteria (RDoC; Insel et al., 2010). The DSM-5 defines mental disorder as “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (APA, 2013, p. 38). Classic examples of mental illnesses are schizophrenia, major depressive disorder, bipolar disorder, obsessive–compulsive disorder, and generalized anxiety disorder. Of course, the DSM-5 includes many more disorders and provides criteria for diagnosing each of them.
We begin by briefly reviewing descriptive epidemiological facts that support the hypothesized link between stigma and the health disparities experienced by people with mental illness. Subsequently, we discuss labeling theory as a conceptual foundation for understanding the bidirectional relationship between stigma and mental illness. Then building on modified labeling theory, we introduce (p. 522) a conceptual model linking mental illness stigma to physical health disparities. We conclude the chapter by identifying directions for future research.
Stigma and the Problem of Physical Health Inequalities for People with Mental Illnesses
Is it possible that developing a mental illness reliably raises one’s risk of developing other, physical illnesses? Does such an increase in risk translate into a shortened life expectancy for people with mental illnesses? And if these effects occur, why do they occur? Research has answered the first two questions with a resounding “yes.” People with diverse mental illnesses are at substantially higher risk for overall mortality (Chesney, Goodwin, & Fazel, 2014; Laursen, Munk-Olsen, Nordentoft, & Mortensen, 2007; Walker, McGee, & Druss, 2015) as well as specific causes of death, such as heart disease, stroke, diabetes, and many cancers (Roshanaei-Moghaddam & Katon, 2009). We propose that the stigma associated with mental illness is a major contributor to this massive physical health inequality. The fundamental idea is that mental illness leads to stigma and that stigma then leads to both increased stress and depleted resources so as to compromise recovery from mental illness and lead to elevated rates of physical illness.
Multiple descriptive facts concerning the connection between mental illnesses and other illnesses construct a picture congenial to a stigma explanation. First, research consistently shows that multiple mental illnesses, not just one, are related to morbidity and mortality. We know this from literature reviews of mortality experience associated with, for example, schizophrenia (Saha, Chant, & McGrath, 2007), anorexia (Sullivan, 1995), and a range of affective disorders, including bipolar disorder, major depressive disorder, and schizoaffective disorder (Roshanaei-Moghaddam & Katon, 2009), all of which show substantially higher mortality rates for people experiencing these disorders. If it were just one mental disorder, it would be possible to argue that the specific form of psychopathology might be at work or that some genetic or biological feature of the specific disorder is also a cause of other illnesses.
Second, the research evidence reveals that no single morbidity or cause of death explains the overall mortality gap between people who have mental illness and those who do not (Walker et al., 2015). If the positive association between mental illness and mortality were entirely due to suicide or entirely due to heart disease, for example, we would be strongly motivated to search for reasons associated with risk factors for these causes of death. However, this is not the case. For example, a meta-analysis of mortality studies focused on people with schizophrenia (Saha et al., 2007) found elevated mortality for 10 of 11 major causes of death ranging from accidents to infectious and cardiovascular diseases. The descriptive pattern suggests a general factor such as stigma that might operate across physical disease outcomes.
A third reason for implicating a general cause for an association between mental illness and mortality is that people with mental illnesses are at much greater risk with respect to several major risk factors for poor health, including smoking (Substance Abuse and Mental Health Services Administration, 2013), obesity (Mitchell et al., 2013; Vancampfort et al., 2013), and being sedentary (Soundy et al., 2013). Again, this general pattern of elevated risk across multiple risk factors suggests a general cause, something that shapes multiple risk factors rather than just one.
Fourth, consistent with the hypothesis that stigma leads to health inequalities for people with mental illnesses, disparities emerge at many points in the progression to disease and death. Risk factors such as those just mentioned might be initial causes of the onset of multiple diseases, but stigma may play a cascading role through biases in health care. People with mental illnesses are less likely to receive health-beneficial primary care screening, including cancer screening (Carney, Jones, & Woolson, 2006; Xiong, Bermudes, Torres, & Hales 2008) and routine checks for blood pressure and cholesterol (Roberts, Roalfe, Wilson, & Lester, 2007). In addition, once a disease develops, people with mental illnesses are less likely to receive widely recognized treatments to forestall the consequences of the disease (Druss et al., 2000).
The fact that inequalities are noted at each of these stages—risk factors for disease onset, approaches to identifying incipient illness, and treatment once illness is identified—implicates a general factor that influences all of these stages. The breadth of the disparities between people with multiple types of mental illness and people without such illnesses suggests the possibility that a general cause attached to mental illness invigorates multiple disease mechanisms that lead to multiple disease outcomes. But why might we think that the stigma associated with mental illnesses is that general cause? One reason is that a very similar pattern exists with respect to Blacks who are exposed to racial stigma.
From an epidemiological perspective, the pattern of results just described for mental illnesses (p. 523) strongly mimics patterns of health outcomes for other stigmatized and discriminated-against groups. Compared to Whites, for example, Blacks are disadvantaged with respect to multiple behavioral and environmental risk factors. They are treated unequally by the medical care system and experience poorer health across multiple disease outcomes (see Chapter 10, this volume). Extensive evidence links these large disparities to White racism (prejudice and discrimination based on a belief in racial superiority of Whites) (Phelan & Link, 2015; see also Chapter 9, this volume). The affinities between racism and what Goffman called “tribal stigma” and between concepts of prejudice and discrimination and stigma (Phelan, Link, & Dovidio, 2008) suggest that if racism produces health disparities for Blacks, stigma could produce health disparities for people with mental illnesses.
Labeling Theory, Modified Labeling Theory, and Bidirectional Processes
If stigma is a possible explanation for physical health disparities between those with and those without mental illness, what are some of the ways in which it might produce such disparities? In order to construct a plausible explanation, we begin with labeling theory within sociology because it strongly makes the bidirectional argument that is emphasized in this part of the book: Illness leads to labeling and stigma, which in turn powerfully shape the social experience of having a mental illness. The stigmatized person is further set apart and made even more different by reactions to his or her original illness condition. This further setting apart stymies recovery from mental illness and helps construct a risk of developing other illnesses. We briefly review classic labeling theory and then consider in more detail modified labeling theory and the role of labeling in the bidirectional relationship between stigma and mental illness and, ultimately, physical health.
Classic Labeling Theory
Labeling theory attends to how people define, categorize, and respond to behavior they define as deviant rather than to the reasons the behavior occurred in the first place. The theory posits that societal reactions to initial manifestations of deviant behavior—the defining, categorizing, and responding—lead to further deviance. Lemert (1951), an early labeling theorist, captured this idea with his concepts of primary and secondary deviance. Primary deviance refers to the initial rule-breaking/norm-violating behavior, whereas secondary deviance refers to the ancillary consequences created by the societal response to primary deviance. For example, a youth’s possession and use of illegal substances might be conceptualized as primary deviance. This primary deviation then results in arrest and incarceration, which carry a potent stigma that induces secondary deviance by cutting off access to legal employment, thereby encouraging engagement in illegal occupations such as selling drugs or engaging in prostitution. Thus, in terms of the language used in this part of this volume, labeling theory is strongly bidirectional.
This focus on bidirectional processes in labeling theory was particularly prominent in Scheff’s (1966) labeling theory of mental illness. An important contribution of Scheff’s theory was his concept of “residual rule-breaking.” Scheff noted that some violations of social rules or norms, such as stealing, trespassing, speeding, and evading taxes, are written down and codified in law. However, numerous others are not, leading Scheff to conceptualize the violation of these unwritten rules as “residual rule-breaking.” The critical insight Scheff provided was that what psychiatrists considered to be the symptoms of mental illnesses broke these residual rules. For example, many of the symptoms of psychosis break taken-for-granted rules about what we are supposed to believe and how we are supposed to act. Pronouncing that one is Jesus Christ, the devil, or Vladimir Putin’s slave breaks deeply shared rules about what is real and what is not. Fitfully rubbing one’s body in an effort to keep imagined bugs off or shouting at people who are not present violate rules about how things should be and how people should behave. However, the concept is not limited to psychosis. As a result of the symptoms of attention deficit hyperactivity disorder, for example, a middle-school student breaks rules about sitting still in class or staying focused on the required task. A person with anorexia appears dangerously thin to family and friends but professes to be too fat and refuses to eat. Even depressed mood or anxiety can be thought of as breaking “feeling rules” (Thoits, 1985) when one is more depressed or anxious than circumstances seem to warrant.
By focusing on the rule-breaking aspect of symptoms, Scheff (1966) directed attention to the social response to such rule-breaking. He constructed nine propositions in his theory, with his ninth and most provocative assertion being that “among residual rule breakers (those displaying initial symptoms), labeling is the single most important cause (p. 524) of careers of residual deviance (stabilized mental illness)” (pp. 92–93).
However, strong rebuttals also emerged, with perhaps the most prominent critic being Gove (1982), who essentially turned Scheff’s (1966) theory on its head by asserting that it was not labeling that caused stable mental illness but, rather, the symptoms of mental illness that led to labeling. Gove further countered that mental illness labeling was far from arbitrary or capricious but, rather, a kind of “last resort” attribution that people came to only after attempting and failing to explain aberrant behavior in other ways. An early but prominent example came from qualitative work on the wives of men who developed serious mental illness. According to Yarrow, Schwartz, Murphy, and Deasy (1955), the wives frequently ignored, downplayed, or explained away the emerging symptoms of their husbands to such an extent that acknowledgment of mental illness as the cause came only after an extreme event such as the involvement of the police. Importantly for our current interest, Gove strongly dismissed stigma as a potential mechanism in any bidirectional process. Stigma was just not that important, he claimed, because as he stated, for the “vast majority of mental patients stigma appears to be transitory and does not appear to pose a severe problem” (p. 280).
Modified Labeling Theory
In the context of the Scheff/Gove debate, Link and colleagues developed a “modified” labeling theory that derived insights from the original labeling theory but stepped away from the claim that labeling is a direct cause of mental illness (Link, 1982, 1987; Link, Cullen, Struening, Shrout, & Dohrenwend,1989). Instead, the theory postulated a process through which labeling and stigma jeopardize the life circumstances of people with mental illnesses, harming their employment chances, social networks, and self-esteem. By creating disadvantage in these domains and others like them, people who have experienced mental illness labels are put at greater risk of the prolongation or reoccurrence of mental illness. The modified labeling theory also provided an explanation as to how labeling and stigma might produce these effects and how key concepts and measures could be used in testing the explanation with empirical evidence.
Link et al. (1989) identified a five-step sequence to explain how labeling and stigma lead to the prolongation or reoccurrence of mental illnesses. The first step in this sequence is the observation that people develop conceptions of mental illness early in life as part of socialization (Angermeyer & Matschinger, 1996; Scheff, 1966; Wahl, 1995). Link et al. conceptualized these beliefs using the symbolic interactionist concept of the “generalized other” (Mead, 1934), a term used to indicate that during socialization, individuals learn the attitude of the community toward many behaviors, objects, and attributes and therefore develop beliefs about how most people will react to these aspects of social life. In the bidirectional model for mental illness, this generalized attitude toward mental illness is captured by assessing an individual’s perception about how most people will respond to a person with mental illness. Once in place, people’s conceptions become a lay theory about what it means to have a mental illness (Angermeyer & Matschinger, 1994). People form expectations as to whether most people will reject an individual with a mental illness as a friend, employee, neighbor, or intimate partner and whether most people will devalue a person with a mental illness as less trustworthy, intelligent, and competent. (For a very similar conceptualization but one generalized to other forms of stigma, see Major and Schmader’s notion of “collective representations” in Chapter 5 of this volume.)
In a second step, the meanings of these generalized beliefs about how most people will treat a person with mental illness differ depending on whether or not an actor is identified as having a mental illness. For people who never develop mental illness and do not experience a potent labeling experience (e.g., psychiatric hospitalization), such beliefs are present but have little personal relevance. For example, a person may believe that people will fear, devalue, and discriminate against someone who has been hospitalized for mental illness, but these beliefs have no personal consequence if the person has never developed mental illness. However, for a person who develops a serious mental illness, such beliefs have an especially poignant relevance because the possibility of devaluation and discrimination becomes personally relevant. If one believes that others will devalue and reject people with mental illness, one may now fear that this rejection will apply personally. The person may wonder, “Will others look down on me, reject me, because I have been identified as having a mental illness?”
In the third step described by modified labeling theory, people who have been labeled as having a mental illness seek to manage the possibility that they may experience rejection. In Link et al.’s (1989) initial formulation, this could involve keeping (p. 525) treatment for mental illness a secret, withdrawing from social contacts that might involve rejection, or educating others in an effort to block the application of stereotypes and ward off rejection. Although such efforts might forestall some experiences of rejection, they can also carry costs such as isolation if withdrawal is used as a coping mechanism.
In a fourth step, consequences ensue that affect social and psychological aspects of people’s lives. If one believes that most other people will devalue and discriminate based on having been labeled as having a mental illness, one might experience a range of feelings, such as shame, feeling different from other people or less worthy of respect, or simply feeling discouraged and anxious. In addition, if one fears rejection, one might approach interactions more tentatively and with less confidence, in turn leading others to like one less and view one as less competent. Finally, if one decides not to ask for a date, seek a job, or make a friend for fear of rejection, a whole host of potential opportunities are forgone. Aspects of this step in the theory have been tested with a broad range of outcomes, in different samples, by different investigators, and often using longitudinal data. These studies generally showed that measures assessing a belief that most people will devalue and discriminate against a person with mental illness were associated with outcome variables including quality of life (Rosenfield, 1997), self-esteem (Link, Castille, & Stuber, 2008; Link & Phelan 2014; Link, Struening, Neese-Todd, Asmussen, & Phelan, 2001; Livingston & Boyd, 2010; Wright, Gonfein, & Owens, 2000), social networks (Link et al., 1989; Link, Wells, Phelan, & Yang, 2015; Perlick et al., 2001), depressive symptoms (Link, Struening, Rahav, Phelan, & Nuttbrock, 1997; Perlick et al., 2007), treatment adherence (Sirey et al., 2001), and treatment discontinuation (Sirey et al., 2001).
The fifth and final step that could extend the value of the theory has not been directly tested. The core idea of this fifth step is that any decrement in self-esteem, challenge to self-efficacy, job loss, constriction of social network, or other untoward consequence becomes a psychosocial risk factor for the development or prolongation of mental disorder. In this way, modified labeling theory proposed that stigma processes become a bidirectional process in mental illness—mental illness leads to stigma and stigma prolongs and/or raises the risk of reoccurrence of mental illness. Of critical relevance to this chapter is the observation that decrements in the social and psychological resources specified in modified labeling theory can also put one at risk for physical illnesses. Specifically, in the conceptual model that follows, we argue that mental illness stigma affects physical health through stress processes and through exclusion from jobs, housing, or educational opportunities that provide resources important for health maintenance.
A Conceptual Model Linking Mental Illness Stigma to Physical Health Disparities
Figure 28.1 depicts processes that could plausibly link mental illness stigma to physical and mental health disparities for people with mental illnesses. On the far right are mental illness (Box G) and (p. 526) physical illness (Box H), the linked outcomes we wish to explain. We discuss the elements of the conceptual model moving from the left to the right. As we do, there is a distinct emphasis on mental illness and particularly on mental illness stigma, but the idea is that these aspects of mental illness stigma have a cascading influence on physical health. In particular, we propose that mental illness stigma may be a strong contributing factor to the dramatic physical health disparities that people with mental illnesses experience.
Initial Causes of Mental Illness Symptoms
Box A in Figure 28.1 lists factors that could cause initial manifestations of the symptoms of mental illness. We include as examples factors in the social environment (e.g., stressful life events, isolation, and poverty), the physical environment (e.g., toxins, nutritional deficits, and infectious diseases), and genetic or epigenetic factors. The main point we seek to make in portraying these factors is to indicate that the initial symptoms of mental illness likely have a disparate set of causes.
Mental Illness Symptoms/Residual Rule-Breaking
In Figure 28.1, Box B represents the variety of symptoms that people with mental illnesses experience, including psychotic symptoms such as hallucinations and delusions, depression, anxiety, obsessive–compulsive symptoms, and so on. In keeping with the idea that there are numerous residual rules (social norms) and that the manifestation of these symptoms breaks these rules (as previously described), we use the term residual rule-breaking to refer to these experiences.
Societal Reactions/Stigma Motivations in Mental Illness Stigma
Reasoning broadly across many stigmatizing circumstances, Phelan et al. (2008) proposed that stigma helps stigmatizers attain ends they desire. They propose three generic ends that people can attain through stigma: (1) exploitation/domination or keeping people down (e.g., slavery and the arrogation of American Indian lands), (2) enforcement of social norms or keeping people in (e.g., The Scarlet Letter), and (3) avoidance of disease or keeping people away (e.g., leprosy) (see Chapter 3, this volume). Although Phelan et al. note that more than one of these motivations can be evident in any particular stigmatizing circumstance, in some instances (as with the parenthetic examples provided previously), one of the motivations seems more prominent than others.
Following on the conceptualization of symptoms of mental illness as residual rule-breaking, we propose that the major initial reason for the stigmatization of people with mental illnesses is an attempt to keep people in. It is interesting to speculate about why it would be so important to keep people in and why people would be so strongly motivated to do so. In some instances, the answer seems quite straightforward, such as when a person with attention deficit hyperactivity disorder disrupts the flow of what needs to be done in the classroom. We seek to keep people in so that we can get on with the task at hand with as little disruption as possible. However, in other instances, the behavior seems quite harmless from the perspective of the observer, such as when a person is deeply engaged in brushing off bugs others cannot see or attending to a voice the rest of us cannot hear.
Why should we care about bringing behavior such as this back within normative boundaries? Goffman (1971) gives a plausible answer in his essay on “normal appearances,” in which he argues that people tend to scan scenes to ensure that everything seems “normal.” When they are judged to be so, people can feel safe and focus on other matters. Non-normative behavior disrupts the capacity to conclude that everything is as it should be and ends up at best unsettling and at worst downright terrifying. Whether this account or others explain why people seek to maintain these micro orders, it is quite obvious that when these rules are broken, people want their validity confirmed and seek to have norm violators brought back in.
Confronted with residual rule-breaking that originates from mental illnesses, people initially seek common-sense solutions to rein in the rule-breaking behavior, such as strongly disapproving of odd beliefs expressed by people with psychosis, admonishing a person with depression to “snap out of it,” or passing favorite foods into the sight lines of a person with anorexia. The interesting point about mental illnesses is that these initial efforts to keep people in ultimately fail.
When efforts to keep people in fail, we might expect, consistent with Phelan et al.’s (2008) observation, that elements of other motivations to stigmatize might be deployed as well. Thus, although there is little reason to suppose that mental illnesses are initially stigmatized so that those who suffer from them can be exploited or dominated for monetary gain, when efforts to keep people in fail, (p. 527) keeping people away can be substituted as a strategy to avoid non-normative behavior. To the extent that keeping people away is more easily achieved when people are relatively powerless, we might expect that keeping people down would also be prominent in the case of persistent mental illnesses—possibilities that we explore next.
Stigma Mechanisms of Minority Stress
In this section, we draw attention to four generic mechanisms in the center of Figure 28.1 in a box labeled “Minority Stress.” We do this to capture the insight prominent in Meyer’s (2003) formulation of minority stress theory that indicates that the stigma processes involved are ones that people in the stigmatized category experience but that others do not. As Meyer states, an elaboration of stress theory may be called “minority stress to distinguish the excess stress to which individuals from stigmatized social categories are exposed as a result of their social, often a minority, position” (p. 676). This notion of an added burden is critical because it helps us understand that the additional adversity might be a contributing cause of physical and mental health disparities. The stigma mechanisms we point to are enacted structural, enacted interpersonal, social psychological/symbolic interaction, and internalized/”self” stigma processes. These mechanisms correspond to the mechanisms in Chapter 1 of this volume of “enacted”(structural and interpersonal), “felt,” “anticipated,” and “internalized,” with “felt” and “anticipated” roughly falling within the domain we label “social psychological/symbolic interaction.” In discussing these generic mechanisms, we propose that each (1) responds to the desire to keep people in, down, and/or away (Box C) and (2) affects resource reduction and stress (Boxes E and F), which then affect mental (Box G) and physical illness (Box H).
Enacted Stigma—Structural Processes
When official labeling through treatment contact occurs in mental illnesses, people encounter a host of structural arrangements that have been created over time to manage people who have such illnesses. These include policies, laws, and institutional conditions and practices. By and large, these structural arrangements accompany the label—especially if that label involves psychiatric hospitalization or involuntary commitment. Having the label is what makes the policy relevant, the law applicable, or the institutional arrangement what one can expect in the treatment context.
In explicating structural factors and how they might impact physical health, we begin by discussing the treatment system as an institutional factor. The treatment system can be conceptualized as an attempt to bring professional intervention to bear in addressing symptoms and thus helping to keep people in. Unfortunately, the literature on treatment often concludes that instead of a “cure,” the benefits achieved by professional treatment are often more in the realm of symptom management and that frequently symptoms persist or return at a later time, as suggested by the chronic course many people with mental illnesses experience (National Institute of Mental Health, 2016). Thus, in light of the framework we are proposing, professional treatment cannot fully satisfy the motivation to keep people in. As a result, we might expect the treatment system to have features that respond to the failure to keep people in with procedures that address the problem of norm violation by keeping people away or down.
The history of institutional treatment for mental illnesses provides vivid examples. For example, mental hospitals—“asylums”—were situated away from the population centers where most patients resided (Rothman, 1971) and developed over time into what Goffman (1961) described as “total institutions” that segregated patients and stripped them of their external identities. Patients were effectively kept “away” and “down” in these institutions. As the use of mental hospitals waned in the latter half of the 20th century, there was hope that less segregation—less keeping people away—would follow. However, this did not occur. Instead, as previously described, “not in my backyard” (NIMBY) processes led to the location of long-term care facilities in what some have described as “psychiatric ghettos” in poor disorganized sections of cities (Pratt, Gill, Barrett, & Roberts, 2013, p. 344). In addition, evidence shows that extremely large numbers of people with mental illnesses now end up in jails and prisons, where the rates of mental illnesses are dramatically higher than in the general population (Prins, 2014). New ways to keep people away and down were developed in the new era of deinstitutionalization.
The main point of the forgoing is to suggest that although the institutional treatment of people with mental illnesses seeks and frequently delivers beneficial treatment, there has also been a historically robust tendency to structure the system to keep people with mental illnesses away. When mental illness develops and official labeling occurs, an individual’s risk of exposure to being kept away (p. 528) escalates. Although not everyone ends up isolated in a distant mental hospital, situated in a “psychiatric ghetto,” or shunted away from treatment into jail or prison, the risk of this happening because of the structure of the system is elevated. And when this occurs, health consequences likely ensue. One of the most robust associations in social epidemiology is the connection between social relationships and health (House, Landis, & Umberson, 1988), a finding that suggests that when isolation occurs, physical and mental health are likely to suffer. Similarly, if board and care homes are located in relatively poor and powerless areas of modern cities, the people assigned to those settings are situated in places where levels of crime, interpersonal violence, infectious disease, and pollution are high and where the availability of safe parks, walkable streets, and grocery stores that are well stocked with fresh fruits and vegetables is low. Thus, people with mental illnesses are situated in contexts that facilitate physical and mental health risks. Finally, if changes in the system shift the location of people with mental illnesses from hospitals to prisons, the people in those settings risk exposure to abuse by guards and prisoners, procure the additional stigma of a criminal record, experience isolation from family and friends, and generally accrue the poor physical and mental health outcomes that prison populations experience (Massoglia & Pridemore, 2015).
Outside the treatment system, policies represent a structural condition that can restrict or ensure access to rights, privileges, and protections. The 50 United States provide a patchwork of laws that prescribe policy toward people with a history of mental health treatment. Laws that restrict people with a history of mental illness from holding elective office, serving on juries, voting, remaining married, and being allowed to have custody of a child are common, characterizing between one-third and one-half of the states, depending on the specific issue (Corrigan, Markowitz, & Watson, 2004). In addition, some states have restrictions barring people with a history of mental illness from specified occupations or barring the location of group homes for people with mental illnesses in particular areas or the operation of a mental health facility within 1,000 feet of a school (Corrigan et al., 2005). And, of course, many states ban people with a history of mental illness from owning a gun or a particular type of gun (handgun) (Corrigan et al., 2005). Laws such as these can affect negative physical and mental health outcomes directly by restricting access to a desired occupation or to beneficial social connections of marriage and child custody. In addition, laws such as these can have indirect effects by signaling whether and to what extent a person with mental illness is a citizen on a par with other citizens in terms of voting, owning a gun, or participating on a jury. This signaling as to whether one is a person of worth, on a par with others, can be reflected in social psychological processes involving stigma as described later.
The examples of structural conditions provided previously focused on the treatment system and on laws pertaining to people identified as having a mental illness. A full accounting would need to go beyond these important domains to include others, such as parity between insurance coverage for mental and physical problems, the institutional practice of shunting people with mental illnesses to psychiatry even when the presenting problem is a physical health condition, and many others. The main point we wish to convey is that through a host of structural conditions, people with mental illnesses are situated in circumstances that increase their risk of health-harming outcomes and decrease their access to health-beneficial resources. Unlike the excellent research with respect to structural stigma as it has disadvantaged lesbian, bisexual, gay, and transgender (LBGT) groups (see Chapter 6, this volume), empirical research on structural stigma as it pertains to mental illness is just beginning to emerge (Evans-Lacko, Brohan, Mojtabai, & Thornicroft, 2012). Research on LBGT populations using longitudinal designs and natural experiments has shown that structural stigma affects a range of mental and physical health outcomes (see Chapter 6, this volume), with one study showing as much as a 12-year difference in life expectancy between low and high structural stigma areas (Hatzenbuehler et al., 2014). Much more research is required, but the propitious findings concerning structural stigma as it applies to other stigmatized statuses suggest that such structural features could play an important part in creating physical health disparities between people with a mental illness and those without one.
Enacted Stigma—Interpersonal Processes
We conceptualized the origin of mental illness stigma as a desire to keep people within normative bounds of belief and behavior—keeping people in. We also noted that when efforts to do so fail, people frequently address the residual rule-breaking that troubles them by keeping people who have (or have had) a mental illness away. Evidence for keeping people away is long-standing and voluminous, (p. 529) emerging from multiple sources, including self-reports of behavioral intentions by the general public, reports of experiences of discrimination by people with mental illnesses, social psychological experiments involving behavior, and audit studies. The main point is that to the extent that a desire to keep people away is operative, people with mental illnesses are likely to be disadvantaged with respect to a host of social determinants of health. First, a strong body of research indicates that being exposed to enacted stigma is stressful and that the stress experienced is harmful to physical and mental health (see Chapter 11, this volume). Second, enacted stigma involves exclusion from key social determinants of health, such as good jobs, robust social networks, adequate housing, and effective medical care. In this way, enacted stigma increases exposure to health risks and decreases access to resources that can be used to create a healthy lifestyle (see Chapter 3, this volume).
Evidence concerning the extent to which the general public seeks “social distance” from people with mental illnesses has accumulated ever since researchers in the area of mental illnesses (Cumming & Cumming, 1957; Whatley, 1959) borrowed the concept from researchers studying race and ethnic relations. The concept as articulated in these early works involved the question of how close one would be willing to be to someone with a mental illness—for example, live in the same neighborhood, work on the same job, be a close friend, or become a family member through marriage.
This tradition of focusing on social distance—a desire to keep people away—has continued to the present day, with recent studies showing that the desire for social distance has remained obstinate in the face of efforts to change it. Multiple cross-sectional surveys in the United States (Pescosolido et al., 2010) and Germany (Angermeyer & Matschinger, 1997) have shown that although goals of moving the general public to a medical model of mental illnesses with genetic and biochemical causes requiring medical treatment were achieved, no change in stereotypes of dangerousness or competence or desire for social distance occurred. Many members of the public readily report a desire to maintain social distance from people with mental illnesses.
Another window into enacted stigma as experienced by people with mental illnesses is self-reports of discrimination experiences. Wahl (1999) conducted a large study of people who had been in treatment for mental illness and found that respondents reported being denied a job (32%), rejected for health insurance (30%), excluded from volunteer work (26%), treated unfairly in legal proceedings (20%), or denied the opportunity to rent an apartment (19%) sometimes, often, or very often as opposed to seldom or never. What might today be called microaggressions, such as hearing people make negative statements about people with mental illnesses (78%), hearing negative comments from the mass media, being treated as less competent (70%), being shunned (60%), or being told to lower one’s expectations (50%), were even more common. Numerous analyses dating from the earliest studies of mental illness stigma to the current day show a similar pattern to that observed by Wahl (Corker et al., 2013; Corrigan, Markowitz, Watson, Rowan, & Kubiak, 2003; Gove & Fain, 1973; Link et al., 2015).
Further evidence of interpersonal discrimination against people with mental illness can be gleaned from experimental work in social psychology. Some of the earliest such research was undertaken by Farina and colleagues in a path-breaking program of mainly experimental research. The research not only brought the experimental paradigm to the study of mental illness stigma but also gave empirical support to many of Goffman’s (1963) observations about the subtle ways in which stigma might affect people. In an initial study, Farina and Ring (1965) sought to directly test whether a mental illness designation would lead to rejecting behavior. They randomly assigned one of a pair of undergraduates to believe that the other in the pair was either “normal” or had been mentally ill. The participants were then assigned a joint task followed by a questionnaire. It was found that when a co-participant was labeled mentally ill, the other subject in the pair preferred to work alone rather than with the labeled person; blamed the labeled person for inadequacies in the joint performance; and viewed the labeled person as more unpredictable, less able to get along with others, less able to understand others, and less able to understand himself. Subsequent studies by Farina and by others (Lucas & Phelan, 2012; Sibicky & Dovidio, 1986) have continued to provide experimental evidence of enacted stigma at the interpersonal level.
Although they are relatively rare, audit studies have also been undertaken as a means of assessing enacted stigma experienced by people with mental illnesses. In one early example, Page (1977) collected a set of advertisements for apartment rentals and randomly assigned landlords to receive calls from (p. 530) student confederates feigning different circumstances. In three scenarios, the caller indicated that she (all callers were female) was a patient in a mental hospital but varied aspects such as whether commitment was involuntary or whether she wanted to come see the apartment right away. The unsurprising finding was that a mention of mental hospitalization sharply restricted the percentage of landlords indicating the apartment was available (23%, 27%, and 30% in the three mental hospital conditions) compared to a control condition (83%). Recently, Hipes, Lucas, Phelan, and White (2016) conducted an audit study of advertised job openings, inserting a gap in the applicants’ resume but explaining that gap differently. In one instance, it was described as being due to a mental hospitalization and in another to physical injury. As expected, significantly fewer callbacks occurred when a history of mental illness was mentioned (Hipes et al., 2016).
In summary, whether we examine the behavioral intentions of the general public, self-reports of people who have had mental illnesses, the findings of social psychological experiments, or the results of audit studies, there is ample evidence that people with mental illnesses experience enacted stigma in interpersonal relationships. This conclusion is supported by the triangulation across different methods that have differing strengths and weakness with respect to internal and external validity. In the context of the theory and concepts forwarded in this chapter, the claim is that this rejection derives from a desire to “keep people away” that takes hold when efforts to “keep people in” fail. Then when the exclusion occurs, it both directly reduces social and economic resources (resource reduction mechanisms; Box E in Figure 28.1) and exposes people to the stress that such exclusion entails (stress mechanisms; Box F), with potentially negative effects on mental (Box G) and physical (Box G) health.
Social Psychological Processes—Symbolic Interaction Stigma
One of the great accomplishments of social psychology in the area of stigma has been its illumination of the many ways in which untoward consequences of stigma can accrue even when direct person-to-person discrimination is not evident. Prominent examples are processes involving “stereotype threat,” a circumstance in which performance is harmed when people feel at risk of conforming to stereotypes (Steele & Aronson, 1995); “aversive racism,” a subtle contemporary form of racism (Dovidio, Gaertner, & Pearson, 2017); and “identity threat,” a situationally triggered concern that one is at risk of being stigmatized (see Chapter 5, this volume). Knowing about stereotypes and anticipating how others might apply them have consequences even in the absence of direct discrimination. Furthermore, as described later, the stigmatized person need not accept that the stereotype is true about him or her or the group to which he or she belongs for negative consequences to emerge. In this chapter, we call these social psychological processes “symbolic interaction stigma” for reasons we describe later, but we note that they correspond closely to the terms of “anticipated” and “felt” stigma presented in Chapter 1 of this volume.
In this section, we present and develop a case for the importance of these social psychological/symbolic interaction processes for the physical and mental health of people with mental illnesses. The claim is that these processes impact health both because they induce stress and because they negatively impact social determinants of health such as good jobs, supportive social relationships, and effective medical care.
The previously described modified labeling theory represents a useful starting point for considering social psychological/symbolic interaction processes in the area of mental illnesses. As a sociologically oriented theory, this approach drew on symbolic interaction theory (Mead, 1934; Stryker, 1980) that directs attention to the observation that people commonly anticipate and rehearse expected interactions. People seek to foretell what others might think, conjure notions about what could transpire, and imagine useful strategies to achieve desired ends—all before an interaction takes place. This sort of “symbolic interaction” can be consequential for self-evaluations and for guiding future behavior. Here, we elaborate a class of concepts that are linked together by the fact that they are all one form or another of anticipated “symbolic” interaction (Link et al., 2015).
Perceptions of societal-level devaluation and discrimination (or “collective representations,” (see Chapter 5, this volume) concern what people think “most people” think about someone identified as having a mental illness. In symbolic interaction terms, this represents interaction with the “generalized other.” For mental illnesses, it involves questions such as “Will most people look down on, lose respect for, and distrust someone with mental illness, and will they avoid marrying, hiring, or socially interacting with such a person?” Even if a person rejects perceived stereotypes and remains (p. 531) certain that he or she is trustworthy, competent, and harmless, such a person may still worry about the reactions of others. He or she may avoid anticipated negative reactions, thereby losing opportunities to apply for a job, ask for a date, seek a desired house rental, or simply engage in some form of enjoyable interaction.
Anticipation of rejection (a form of anticipated stigma) is the person’s own forecasting of whether rejection will occur. How much does the person worry that others will look down on him, devalue her opinions, or not want to date him or hire her? The concept is an extension of modified labeling theory that focused, as described previously, on what people thought most other people believed about a person who developed mental illness. Implicit in the theory was the idea that a person’s perception that most people devalue and discriminate against people with mental illnesses would translate into a personal worry about rejection. As have others (Quinn & Chaudoir, 2009), Link et al. (2015) developed a measure of anticipation of rejection as an extension of modified labeling theory. Respondents were asked how often in the past 3 months they worried “that employers might not hire you if they knew you had been hospitalized for mental illness?” or felt “that people would look down on you because of your hospitalization?” Again, this symbolic interaction—an anticipation of a negative reaction—could be harmful to physical and mental health in many ways, being experienced as stressful or blocking opportunities when people avoid potentially beneficial associations for fear of rejection.
Stigma consciousness is a concept developed by Pinel (1999) regarding race, gender, and sexual minority bias that Link and Phelan (2014) applied to the area of mental illnesses. Stigma consciousness is an anticipation of, and an enduring concern about, whether one’s stereotyped status is a (the) central feature guiding how others evaluate and relate to oneself. Link et al. (2015) constructed a stigma consciousness scale relevant to people with mental illnesses that included statements such as “Most people do not judge someone on the basis of their having a mental illness” and “I almost never think about the fact that I have a mental illness when I’m around others.” Because it involves anticipation about what others might be thinking, stigma consciousness coheres with the theme of symbolic interaction regarding stigma and is also another form of anticipated stigma as described in Chapter 1 of this volume. If present, stigma consciousness can be harmful because it signals that the stigmatized status is generally salient—on the person’s mind—and therefore an active impediment in social interactions. For example, if a person with mental illness suspects that general medical staff will prominently view him or her as a “psych case,” the person may be less inclined to access needed physical health care, flu shots, or preventive health screening.
Rejection sensitivity is a concept developed by Downey and Feldman (1996) that refers to the anxious expectation of rejection from others. Originally applied to the anticipation of rejection from significant others, the concept was extended to Blacks by Mendoza-Denton, Downey, Purdie, Davis, and Pietrzak (2002). Link and Phelan (2014) applied this concept to the area of mental illness stigma and relabeled the scale “concern with staying in,” based on the observation that people with mental illness frequently fear that others will view them as symptomatic and unable to stay within normative bounds of feelings, beliefs, or behaviors. Concern with staying in was assessed by asking the degree of concern respondents would feel in scenarios such as the following:
Imagine that you are having an argument with a friend who knows about your mental illness, and you are really upset and angry about some of the things he is saying. How concerned or worried would you be that, if you raise your voice and act angry, he will think you’re losing control and showing signs of mental illness?
A heightened level of “rejection sensitivity” or “concern with staying in” has the potential to be harmful in several ways. For example, constant worry that people are scanning you for evidence that you may be developing symptoms again is likely unpleasant and stressful. In addition, a concern about staying in—reining in one’s opinions or failing to complain in the face of unfair treatment for fear that others will see the resurgence of symptoms—disrupts social interaction. To the extent that it does so, interactions in work or friendship contexts may be harmed, thereby affecting social determinants of physical and mental health.
In summary, research on mental illness stigma has identified several constructs that can be characterized as social psychological processes involving symbolic interaction. However, what is the state of the evidence concerning whether these constructs are driven by stigmatizers’ desires to keep people in, away, or down (Figure 28.1, Box C) and then in turn lead to resource reduction (Box E) and/or (p. 532) induce stress in the stigmatized (Box F), which in turn lead to physical and mental illness outcomes (Boxes G and H)?
The empirical evidence concerning the first link—that is, between stigmatizers’ motives to keep people in, away, or down (Figure 28.1, Box C) and symbolic interaction stigma (Box D)—is sparse. At this point, the connection is supported by reasoned conjecture deriving from theory and a close correspondence between the worries and concerns that people with mental illnesses report and the motives of stigmatizers (Link & Phelan, 2014). First, concerning theory, there is the idea that power directed toward desired ends is exerted not only through policies (structural stigma) and direct rejection but also by inducing the disadvantaged (including the stigmatized) to carry out the interests of the powerful (Bourdieu, 1987). This would happen if the desires of stigmatizers produced forms of symbolic interaction stigma that then resulted in keeping people with mental illnesses in, away, and/or down. Such a conjecture is supported by a close correspondence between the worries people express about staying in (rejection sensitivity/concern with staying in) and their anticipations of rejection if they were to venture out and not succumb to staying away. Furthermore, a prominent concern expressed in the scales measuring the concepts is the possibility of being devalued—being downwardly placed. In their imaginative rehearsal of how they might be treated by stigmatizers, people with mental illnesses are induced to stay in, away, or down, thereby satisfying the motives that stigmatizers desire (Link & Phelan, 2014). The weak point in this conjecture is that we cannot say that stigmatizers agentically promote this process—a direct and obvious causal link between stigmatizers’ motives and the imaginative rehearsal of the stigmatized is difficult to draw.
The theorist Bourdieu (1987) asserts that the ambiguity of such a causal link is propitious for the powerful because they get what they want without having their motives recognized—their motives are hidden or “misrecognized,” as Bourdieu states, in the actions of the stigmatized. Still, some way of causally linking the actions of stigmatizers to symbolic interaction stigma is necessary. The best possibility in our view is to conceive of the various forms of stigma (structural, interpersonal, and symbolic interaction) in a system of mutual influence. Structural and interpersonal stigmas are the context that induces symbolic interaction stigma—people anticipate stigma because it happens with some regularity. Symbolic interaction stigma is then an efficient way to keep people in, away, or down because the stigmatizer need not be present, need not personally engage in rejection, or need not take any responsibility for what is transpiring. A system-based proposition, then, is the idea that one form or level of stigma might be more prominent when another declines. In light of such a system-based explanation, we might expect that if the processes involved in symbolic interaction stigma were to begin to fail—if people with mental illnesses began to refuse to choose staying down, in, or away—then stigmatizers would invigorate interpersonal rejection and develop policy to enact more stringent structural stigma. The idea is that the causal link between motives and symbolic interaction stigma is most likely to be revealed when the system begins to fail. Nevertheless, although such a lens might give us some purchase concerning whether the connection was a causal one, at this point the connection remains untested.
Evidence of the second connection, between symbolic interaction stigma (Figure 28.1, Box D) and both resource reduction (Box E) and stress (Box F), is critical to a stigma explanation for physical health disparities because our model posits that it is through these mechanisms that disparities are produced. The strength of the evidence varies with the construct in question. Link’s (1987) perceived devaluation/discrimination scale concerning people’s views of how most people view those with mental illnesses has been used in longitudinal studies, and in the context of quasi-experimental approaches to inference, to identify connections to resource reduction (jobs, money, and social connections) and manifestations of stress (demoralization) (for a review, see Link & Phelan, 2013). In addition, this measure has been shown to be consistently and quite strongly related to psychosocial resources, especially self-esteem (Livingston & Boyd, 2010). Other measures mentioned previously are much newer, having been borrowed from other domains of stigma in social psychology. The evidence relevant to them is consistent with the hypothesis that these constructs induce stress and reduce resources, but the data are cross-sectional and the samples small (Link & Phelan, 2014; Link et al., 2015). However, the case for the importance of these constructs in mental illness is enhanced by their use in other domains of stigma and the usefulness they have shown in those domains with respect to inducing stress and depleting resources in ways that are directly pertinent to physical health (Pachankis, Goldfried, & Ramrattan, 2008; Pinel & Bosson, (p. 533) 2013; Quinn & Chaudoir, 2009). Taken together, there is sufficient theory and evidence to propose these symbolic interaction stigma constructs as potential determinants of reduced resources and experienced stress that will in turn affect physical and mental health.
The idea of internalized stigma has a very long history, tracing back to Clark and Clark’s (1940) studies of Black children’s preferences for White dolls. The concept remains prominent in the current era in concepts such as internalized homophobia (Meyer, 1995) and internalized racism (Johnson-Ahorlu, 2012). In the area of mental illnesses, Corrigan and Watson (2002) are best known for having developed the concept of “self-stigma.” As they state, self-stigma accompanies public stigma as a “second misfortune” that results when “persons with mental illness, living in a culture steeped in stigmatizing images, may accept these notions and suffer diminished self-esteem and self-efficacy as a result” (p. 35). These scholars drew on social cognitive theory to conceptualize stereotype awareness as being cognizant of societal stereotypes, stereotype agreement as the belief that the stereotypes are true, self-concurrence as the belief the stereotypes are true about the self, and self-esteem decrement as the process of losing respect for oneself because one fits the stereotypes. Self-stigma exists when this internalization process is complete.
A substantial literature on self-stigma in people with mental illnesses has developed throughout the years. Measures have been constructed (Corrigan et al., 2012; Ritsher, Otilingam, & Grajales, 2003), meta-analyses attending to sources of self-stigma have been undertaken (Livingston & Boyd, 2010), and systematic reviews of efforts to intervene to address self-stigma have been presented (Mittal, Sullivan, Chekuri, Allee, & Corrigan, 2012). A strong case has been made for the role of self-stigma in blocking recovery and reducing life chances. In terms of the reasoning in this chapter, the internalization of stigma or self-stigma keeps people down. Being downwardly placed is both stressful and leads to resource reduction by blocking the activities of an efficacious self. Stress and resource reduction are then plausibly related to physical and mental health.
To this point, we have argued that a cascade of circumstance starting with initial manifestations of mental health symptoms, followed by societal reaction to those symptoms, create a circumstance of minority stress (structural, interpersonal, symbolic interaction and internalized stigma) that leads to the reduction of resources (Figure 28.1, Box E) and to the experience of stress (Box F). We now turn briefly to evidence linking these latter two mechanisms to physical and mental health outcomes.
Several other chapters in this handbook have mentioned socioeconomic factors as potential social determinants of health (see Chapters 8 and 17). Here, we refer especially to Chapter 3 by Link, Phelan, and Hatzenbuehler because it makes the case for resource reduction as a major influence on health inequalities between groups who are stigmatized and groups who are not. Briefly, Link et al. argue that resources of knowledge, money, power, prestige, beneficial social connections, and freedom (listed in Figure 28.1, Box E) can be used to gain a health advantage. When some new health-enhancing knowledge or technology becomes available, those most propitiously situated with respect to such resources benefit the most, creating a health disparity. Similarly, when a health-threatening event such as a natural disaster occurs, those better situated with respect to such resources are better able to withstand or avoid any health-harmful consequences. Furthermore, the resources identified are “flexible”—that is, they can be deployed no matter what the known risk and protective factors happen to be or which diseases are having the most prominent influence on human health at a given time. For example, if the problem is cholera in the 19th century, a person with greater resources might be expected to be better able to avoid areas where the disease is rampant, and highly resourced communities might be expected to be better able to prohibit entry of infected persons. If the problem is heart disease in the current era, one would expect that a person with greater resources is better able to maintain a heart-healthy lifestyle and get the best medical treatment available (Phelan, Link, & Teranifar, 2010). It is this flexibility that allows for the re-expression of associations between such resources and morbidity and mortality in different places and at different times. This capacity for re-expression led Link and Phelan to socioeconomic status, which embodies many of these resources as a “fundamental cause” of health disparities.
Originally, Link and Phelan (1995) conceptualized socioeconomic status (SES) as a fundamental cause, with knowledge, money, power, prestige, and beneficial social connections as SES-related (p. 534) resources. Subsequently, Link and Phelan extended the notion to racism as a fundamental cause, adding freedom to the list of flexible resources in Phelan and Link (2015) and to stigmatized statuses more generally as a fundamental cause in Hatzenbuehler, Phelan, and Link (2013) and Link et al (Chapter 3, this volume). The main significance for the issue at hand is that as stigma reduces access to flexible resources for people with mental illnesses, it simultaneously limits their capacity for a long and healthy life. Based on this argument and evidence, in Figure 28.1, we have placed arrows from resource reduction (Box E) to mental (Box G) and physical illnesses (Box H).
The second main mechanism we conceptualize in Figure 28.1 is a stress process mechanism that includes two components: exposure to environmental stressors and stress-related pathophysiological processes (see Box F).
Robust literatures in psychology and medical sociology reveal compelling evidence that exposure to stressful circumstances conveys risk for a multitude of untoward health outcomes, particularly when individuals do not have social and personal resources that might help them cope with these circumstances (Carr & Umberson, 2013; Carver & Connor-Smith, 2010; Thoits, 2010). Because this literature has been thoroughly reviewed in the sources just cited, we do not engage the detailed evidence that these sources already cover so well. However, we draw attention to one element of this literature that is particularly important to our argument, namely the idea that both exposure to stressful circumstances and the capacity to manage them effectively are strongly patterned by a person’s positional location in the social structure (Aneshensel, 2009; Pearlin, 1989; Turner, Wheaton, & Lloyd, 1995). For example, one’s occupational position shapes many health-related circumstances, including exposure to toxins and dangerous machines, the inability to control the pace of work, and the quality of medical care coverage. This patterning, the claim is made, helps researchers understand why health disparities between people differentially located in the social structure (e.g., by race, ethnicity, class, and gender) are observed. This element is critical to our conceptual model because we claim that mental illness labeling confers a structural position (see the section on structural stigma) that also influences exposure to many different health-related risk factors. Consider one example. To the extent that NIMBY (Not In My Backyard) processes (Dear, 1992) ensure the location of board and care homes for people with serious mental illnesses in the most undesirable locations of the city where residents do not have the clout to exclude such homes, the people with mental illnesses who are located in these settings are at heightened risk of circumstances that can be stressful, including violence, noise, pollution, crowding, infectious disease, and inadequate city services. Thus, stigma processes associated with mental illness shape exposure to stressful experiences that may exacerbate mental illness and make the likelihood of physical illness greater.
Here, we put forward the widely supported idea that environmental stressors induce pathophysiological processes that lead to physical health problems. Among these are effects on the hypothalamic–pituitary–adrenal axis (the neuroendrocine system that controls responses to stress), allostatic load (wear and tear on the body as operationalized by multiple biomarkers), and telomere length (as a marker of aging) (Burke, Davis, Otte, & Mohr, 2005; Geronimus, Hicken, Keene, & Bound, 2006; McEwen, 1998). These concepts are discussed in greater detail in the cited works and also in Chapter 8 of this volume. Their significance here is that they represent one way in which mental illness stigma might affect physical and mental health through heightened exposure to stressful circumstances.
Mental Illness, Physical Illness, and Their Comorbidity
In this section, we describe aspects of mental (Figure 28.1, Box G) and physical (Box H) illness as well as the relationship between the two as they might be affected by mental illness stigma. As specified within Box G in Figure 28.1, we conceptualize three ways in which mental illness stigma might be implicated in a bidirectional relationship with mental illness. First, stigma might impede recovery, leading to the prolongation of an episode of mental illness. Second, stigma processes might put a person who has recovered from a mental illness at risk of a reoccurrence of the disorder they initially experienced. Third, the experience of stigma associated with one mental illness might increase the risk of developing another. For example, with the development of schizophrenia, stigma experiences might (p. 535) ensue that are stressful and dispiriting, thereby leading to the development of depressive or post-traumatic stress disorder.
As specified within Box H in Figure 28.1, by inducing stress or reducing resources, mental illness stigma could affect physical health by influencing either the initial onset or the duration of a physical health condition. Because there is substantial evidence of comorbidity between mental and physical illness, we show arrows going back and forth between Box H and Box G in Figure 28.1. Although the specific connections between physical and mental illnesses have not been definitively identified, there is the possibility that physical illnesses cause mental illness (e.g., depression following stroke), mental illnesses cause physical illnesses (schizophrenia as a risk factor for cardiometabolic disease), or common causes influence both (stigma, stress exposure, and resource reduction). It seems likely that all three possibilities operate depending on circumstances. This set of causal connections suggests that if mental illness stigma affects either mental illness or physical illness, it is likely to affect the other set of illnesses as well because of the strong comorbidity between the two.
Conclusion and Future Directions
Enormous physical health disparities separate people with mental illnesses from those without them. The central purpose of this chapter was to bring forward the possibility that stigma processes play a major role in generating these disparities. Situated in the “bidirectional” part of this volume, this chapter engaged the idea that initial manifestations of mental illness induce stigma, which in turn feed back to influence the illness. However, we expanded our consideration of bidirectional processes to also include pathways from mental illness stigma to physical illness. We began our exploration of these processes with the societal origins of mental illness stigma, which we viewed as residing in the desire to bring the non-normative behaviors and feelings that are central to mental illnesses “back in”—back within normative bounds. When professional and common-sense efforts to do so fail, efforts to keep people away become more prominent, as does a tendency to render people powerless in their norm violation by keeping them down. This keeping of people down, in, or away is facilitated at the structural level by policies and procedures that separate, restrict, and downwardly place people with mental illnesses; at the interpersonal level by actions that reject and exclude; at the symbolic interaction level by anticipations of rejection that are real in their negative consequences; and at the personal level when negative stereotypes are internalized.
We frame these mental illness stigma processes as “minority stress” to bring attention to the fact they are only problematic for people with mental illnesses—they are added burdens that people without mental illnesses need not confront. This framing as an “added burden” suggests the possibility that an additional load of health disadvantage—a health disparity—occurs because people with mental illnesses are exposed to these stigma processes. Of the multitude of mechanisms linking these aspects of stigma to physical and mental health, we pose two generic ones: resource reduction and stress. When stigma processes exclude, deny, and downwardly place, people lose key social and psychological resources that they might otherwise deploy to craft a healthy lifestyle or situate themselves propitiously with respect to health risks and protective factors. An equally compelling and directly related mechanism is stress exposure, as the process of exclusion, rejection, and diminishing engenders the experience of stress that cascades through well-known processes to produce pathophysiology.
Although the stigma explanation we created is a plausible contributor to physical health disparities between people with and those without mental illnesses, other factors are likely involved as well. Such factors include smoking, eating comfort foods, drinking in excess, and using illegal drugs as a means of self-medicating to avoid the dysphoria that accompanies many mental illnesses. Although this very likely contributes to the disparity, it must be kept in mind that in addition to the mental illness itself, stigma can also contribute to the dysphoria that drives these harmful health behaviors. Also, mental illnesses are often disabling, sometimes extremely so, such as when the depressed person cannot get out of bed or the person with schizophrenia is too symptom-ridden to work. Such disability can lead to resource reduction and can also be experienced as stressful independent of stigma processes. Again, as some of the work we have cited previously has shown, stigma processes operate above and beyond illness-related disability in influencing access to jobs, social relationships, and self-confidence. Ultimately, it is likely that stigma processes will join with factors such as the ones mentioned previously to develop a complete explanation of physical health disparities in people with mental illnesses. Thus, a clear implication for future work on mental illness stigma and physical health is to conduct research (p. 536) that comprehensively assesses health behaviors (e.g., smoking, diet, and physical activity) as well as detailed mental health assessments that capture the impairment that the mental illnesses in question might involve. In addition, it would be ideal to have longitudinal research that can begin to parse the causal ordering of relationships between mental illness stigma, health behaviors, and any impairments that occur with mental illness.
We conceive of the explanation and accompanying conceptual model presented in this chapter as representing a plausible model that needs further testing. Its plausibility is enhanced by three features. First, the concepts employed (e.g., structural stigma, stigma consciousness, and rejection sensitivity) describe realities that people experience and that can be captured by measures and have been shown to be related in meaningful ways to other concepts. The existence of these concepts helps animate the explanation so that a potential role for stigma in physical health disparities can be imagined. Second, there is substantial evidence for some of the connections we propose, such as connections between several stigma processes and a self-esteem decrement in people with mental illnesses. Other connections are supported because they have been found to be influential for other stigmatized groups, such as the connection between structural stigma experienced by gays and lesbians and mental health morbidity and physical health mortality (see Chapter 6, this volume). The support that does exist for some links suggests the plausibility that support for other links might also be found or enhanced. Third, the physical health disparities we seek to explain are experienced by other groups such as Blacks and sexual minorities. As evidence accumulates that stigma-related processes are at work in disparities for these groups, it enhances the plausibility that stigma-related processes might be implicated in physical health disparities for people with mental illnesses. Of course, plausible does not mean confirmed. There are many aspects of the explanation/model that need further testing and more complete evidence.
With respect to what is needed to advance research in this area, perhaps the most obvious action needed is to include physical health outcomes in studies of mental illness stigma—which is currently extremely rare. For example, the emerging body of research that is developing mental illness stigma interventions and testing them in randomized or quasi-experimental designs (Mittal et al., 2012) might include health behaviors, biomarkers, and other health-relevant measures as secondary outcomes. Other parts of the model might be tested by targeted experiments that alter the salience of the mental illness stigma in particular contexts and then examine biomarkers of stress or health behaviors such as smoking or eating comfort foods. In addition, as previously mentioned, impressive research on structural stigma as it relates to sexual minority status has been undertaken, and similar work could be implemented in the area of mental illnesses with physical health as the outcome. However, perhaps the greatest yield would be derived from a prospective population-based longitudinal study that oversamples people who have been labeled as having a mental illness and carefully assesses stigma, mental illness and its impairments, as well as physical health and health behaviors in multiple assessments over time. Such a study would be able to test multiple predictions made by the model and thereby provide the most comprehensive tests of the predictions it makes.
Finally, we turn to a consideration of this chapter in light of the overall ambition of the volume. The volume aims to elucidate how stigma processes are implicated in the social patterning of physical health problems. The project brought forward in this chapter is one that could not have been imagined three short decades ago and was not part of the original conceptualizations of Goffman and Scheff. The idea that mental illness stigma might be involved in patterns of physical health for people with mental illnesses is one that needed the great expansion in theory, concepts, and measures that has occurred in the social sciences in recent times. However, armed with concepts such as minority stress, structural stigma, identity threat, rejection sensitivity, expectations of rejection, stigma consciousness, and self-stigma, a plausible story can be constructed as to how mental illness stigma, through mechanisms of resource reduction and stress, can compromise physical health. If further evidence supports this formulation, the ideas set forth in this chapter will join other chapters in this volume in suggesting the many ways in which stigma is implicated in the social patterning of disease and death. And, to the extent that the overall agenda is realized, we will know that when social scientists study stigma, they simultaneously provide critical evidence about the health profiles individuals can expect to experience and the length of the lives people can hope to enjoy.
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